.

Job Application

Personal Information

First Name *

Middle Name *

Last Name *

Driver's License Number *

Driver's License State of Issue *

Primary Phone Number *

Alternate Phone Number

Email Address *

Current Address

Current Street Address *

Apartment Number

City *

State *

Zip Code *

	Start Date at this Address
Month	Start Date at this Address
Year	Start Date at this Address

Mailing Address, if Different

City

State

Zip Code

Questions

How did you hear about employment opportunities at New Horizon Services? *

Are you legally eligible for employment in the United States of America? *

Yes

No

Are you 18 years of age or older? *

Yes

No

If you are under 18, can you provide required proof of your eligibility to work? *

Yes

No

Are you a citizen of the United States of America? *

Yes

No

If you are not a citizen, does your immigration status permit you to work? (Proof of citizenship or immigration status will be required upon employment) *

Yes

No

Were you previously employed by a Community Service Provider? *

Yes

No

If so, give dates and positions:

Please list the name and department of any relative already employed by New Horizon Services:

If you were to be hired, what date would you be available for work? *

Are you willing to travel if your job requires it? *

Yes

No

Open to Discussion

If so, willingness to travel:

Summarize any special training, apprenticeships, or skills that may assist you in performing the position you are applying for:

0/1000 characters

Is there any additional information you feel may be helpful to New Horizon Services in considering your application?

0/2000 characters

Additional Questions

If hired, do you have the means of transportation to get to and from work? *

Yes

No

Have you ever been convicted of a felony, or for child abuse or sex-related crimes? *

Yes

No

If YES, please explain. (A conviction will not necessarily disqualify you from employment.) *

Are you listed on the State Registry as having been convicted of abuse, neglect or exploitation? *

Yes

No

Have you been convicted of a moving violation in the past three years? *

Yes

No

Do you currently use illegal drugs? *

Yes

No

After reviewing the job duties, can you do the job tasks required without special accommodations? *

Yes

No

If NO, please explain any accommodations you need: *

Do you have a current Adult CPR certification card? *

Yes

No

Do you have a current First Aid certification card? *

Yes

No

What position(s) are you applying for? *

Direct Support Professional

Administrative Assistant

Other Other

Education History #1

Institution Type

Name of Institution

City:

State:

Degree Type

Description of Degree / Licensure

Year Completed

GPA (if known)

Start Date +

End Date +

Education History #2

Institution Type

Name of Institution

City:

State:

Degree Type

Description of Degree / Licensure

Year Completed

GPA (if known)

Start Date +

End Date +

Education History #3

Institution Type

Name of Institution

City:

State:

Degree Type

Description of Degree / Licensure

Year Completed

GPA (if known)

Start Date +

End Date +

Employment History #1 (Current Employer)

Company Name *

Supervisor/Manager *

Phone Number *

Position *

Start Date * +

End Date * +

Ending Salary / Hourly Wage *

Reason for Leaving *

May we contact? *

Yes

No

Employment History #2 (Previous Employer)

Company Name

Supervisor/Manager

Phone Number

Position

Start Date +

End Date +

Ending Salary / Hourly Wage

Reason for Leaving

May we contact?

Yes

No

Employment History #3 (Previous Employer)

Company Name

Supervisor/Manager

Phone Number

Position

Start Date +

End Date +

Ending Salary / Hourly Wage

Reason for Leaving

May we contact?

Yes

No

References

Reference 1

Reference Type *

Reference's Full Name *

Email Address *

Phone *

Describe this reference's relationship to the applicant. *

Reference 2

Reference Type *

Reference's Full Name *

Email Address *

Phone *

Describe this reference's relationship to the applicant. *

Reference 3

Reference Type *

Reference's Full Name *

Email Address *

Phone *

Describe this reference's relationship to the applicant. *

Professional Certification / License

Certification/License Name

Certification/License Type

Issuing Agency

Issuing State

Certification/License Number

Issue Date +

Expiration Date +

Please submit a copy of your resume if you have one.

Acknowledgements

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void and will be cause for termination, whenever discovered. I authorize New Horizon Services to conduct any investigation it deems appropriate concerning my application. I hereby authorize and request former employers, personal references, schools, government agencies, health care providers, and all other persons and organizations to disclose credit, criminal record, employment and any other information that may be sought in connection with this application. I hereby release all of the above mentioned from all liability in connection with those disclosures. I further authorize the companies to disclose to others any information it may have concerning my employment, character, and qualifications, including information gained from this application and the investigation of this application. I herein release the companies from all liability in connection with those disclosures.

By signing herein, you are acknowledging that you have read and understand the terms of this release. *

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